Sepsis and associated complications contribute to a not inconsiderable extent to morbidity and mortality in humans. In most cases, sepsis can be attributed to an infection with gram-negative bacteria when high endotoxin concentrations reach the body and have a systemic effect.
Endotoxins are lipopolysaccharides (LPSs) in the cell wall of gram-negative bacteria and are released by cell lysis and cell division. In fact, lipopolysaccharides are the most common lipid component of the outer cell membrane of gram-negative bacteria. Endotoxins are pyrogenic substances, and the individual affected responds with a strong inflammatory reaction and fever when endotoxins enter the body, for example during the course of microbial poisoning, and, as key mediators, cause an uncontrolled activation of the mononuclear phagocyte system. An accumulation of endotoxins in the blood circuit as a result of endotoxemia leads to an uncontrolled activation of the immune cells and to an imbalance of the coagulation system. This can lead to sepsis, which is characterised inter alia by high fever, low blood pressure and, in severe cases, by multi-organ failure. Sepsis is a condition to be taken very seriously; the lethality of individuals with severe sepsis or septic shock is approximately 30-60% depending on the degree of severity of the condition. Endotoxemia as a result of an infection with gram-negative bacteria is one of the most common causes for the occurrence of a systemic inflammatory response (“systemic inflammatory response syndrome”, SIRS), sepsis, severe sepsis or septic shock and the resultant serious complications. Patients with jeopardised immune defence, such as liver patients or chemotherapy patients, are susceptible to bacterial infections and thus display symptoms of endotoxin poisoning. Endotoxemia may also occur in the case of acute liver failure or acute decompensation with chronic liver failure, thus resulting in the development of states that are very similar (from a biochemical viewpoint) to sepsis. By way of example, acute decompensation may occur in patients with chronic liver failure. In this state, the endotoxins originating from the normal intestinal flora pass the intestinal barrier and stimulate the release of inflammation mediators in the body and therefore cause a sepsis-like state.
Furthermore, septic states can also be triggered by gram-positive bacteria, viruses and fungi.
As mentioned, it is generally known that an uncontrolled activation of the immune cells and an imbalance of the coagulation system may occur in the case of sepsis and other serious conditions. The uncontrolled activation of the mononuclear phagocyte system stimulates an excessive release of inflammation mediators, in particular of cytokines (also referred to as cytokine storm or hypercytokinemia). Cytokines are key mediators in the case of sepsis and septic shock. Tumour necrosis factor (TNF-α, often also referred to merely as TNF) and interleukin-1β (IL-1β) can be cited as the most important pro-inflammatory examples. Further important pro-inflammatory cytokines include IL-6 and IL-8. The initially released cytokine TNF-α triggers a biological signal amplification via a mediator cascade, thus resulting in physiological changes, including severe disruptions to the biological balance and subsequently to circulatory collapse and multi-organ failure. The clinical picture of sepsis correlates with high blood concentrations of the key mediator TNF-α, but also of other cytokines, such as IL1-β, IL-6 and IL-8 in the case of the pro-inflammatory phase or IL-10 or IL-13 with the occurrence of an anti-inflammatory phase, in which the pro-inflammatory mediators inclusive of cytokines have very low concentrations. Furthermore, other serious conditions, such as chronic inflammatory intestinal diseases, psoriasis and rheumatoid arthritis are also associated with excessive TNF-α release.
Besides the intensive medical treatment applied as standard, antibiotics or corticosteroids, immunoglobulins and also circulation-assisting drugs in particular are used for the treatment of sepsis.
A disadvantage of antibiotic therapy is the increasing spread of antibiotic-resistant bacteria. Furthermore, endotoxins are increasingly released by the antibiotic and the accompanying destruction of the bacteria cells, which in turn leads to an increased distribution of inflammation mediators. In addition, an administration of antibiotics is often associated with side effects, such as changes to the intestinal flora or allergic reactions. The attempt to use antibiotics against the key factor TNF-alpha failed, since with this method the reduction of the TNF concentration to zero or very low values appeared to trigger an anergic situation, which was accompanied by a higher mortality compared with the control group. The therapeutic use of specific antibodies against LPS and TNF-α is technically very complex and is therefore associated with high costs.
By means of extracorporeal blood or plasma purification systems (therapeutic apheresis method), it is therefore attempted, as will be described in greater detail hereinafter, to remove the aforementioned cytokines, in particular the factor TNF-α, in such a way as to normalise the concentrations of these cytokines so as to thus avoid the anergic (anti-inflammatory) phase. Endotoxins can be eliminated by means of what are known as LPS-adsorbers (for example the adsorber Toraymyxin®) so as to thus avoid a release of the pro-inflammatory cytokines, which naturally also reduces the anti-inflammatory response.
Apheresis methods are methods carried out extracorporeally, in which pathophysiologically relevant blood and plasma components, for example biomolecules such as (glycol) proteins, peptides, lipids, lipoproteins and lipopolysaccharides, but also blood cells and blood plasma, are removed. Apheresis methods can be used on the one hand for diagnostic and therapeutic purposes, but on the other hand also constitute a very effective possibility for obtaining certain blood components from healthy individuals in sufficient quantity and with sufficiently high purity. Great importance is attributed to therapeutic apheresis, since, with certain indications, this is often a very effective alternative, at the same time having few side effects, compared to treatment with drugs. In the case of plasma apheresis methods, the plasma can thus either be completely separated or replaced by a substitute solution, or only certain components, such as cytokines LDL, endotoxins or immunoglobulins, are removed therefrom by means of an adsorber, and the plasma is then returned again to the donor/patient. Compared with the aforementioned treatment strategies using drugs, therapeutic apheresis methods also have the advantage that the treatment is stopped at any time with immediate effect by switching off the apheresis apparatus.
Apheresis methods and adsorber materials for eliminating toxic and/or harmful blood components are well known in the prior art. Adsorber materials which specifically adsorb cytokines, in particular TNF-α, and/or endotoxins (LPSs), and remove these from bodily fluids such as blood or plasma are also known.
Document US 2001/0070424 A1 discloses an adsorber material based on a porous polymer, which has at least one transport pore with a diameter from 25 to 200 nm and also effective pores with a diameter from 10 to 25 nm. Inter alia, the polymer may also be a non-ionic resin (neutral resin). The adsorber is used to remove protein molecules, in particular cytokines and β2 microglobulin.
Document WO 2011/123767 A1 discloses a method for treating inflammation, wherein a therapeutically effective dose of porous adsorber particles for adsorbing inflammation mediators is administered to a patient, wherein the total pore volume with a pore size from 5 to 300 nm is greater than 0.5 cc/g to 3.0 cc/g.
In WO 2003/090924 a porous separation matrix for separating blood components is described in conjunction with inflammation processes. The separation matrix has a pore size from 5 μm to 500 μm and also at least one functional group arranged on the matrix.
DE 19515554 A1 discloses methods and apparatuses for simultaneous extracorporeal elimination of TNF-α and lipopolysaccharides from whole blood and/or blood plasma. Here, the blood or blood plasma is guided in an extracorporeal perfusion system via a porous cation exchanger material and an anion exchanger material. The porous carrier materials described therein have a mean pore diameter of <30 nm and/or a molecular exclusion size for globular proteins of <106 Dalton and in particular <2×104 Dalton.
Neutral resins for removing toxic components, including cytokines, from a bodily fluid are also disclosed in WO 2005/082504 A2. WO 2005/082504 A2 describes a detoxification apparatus, which comprises activated carbon and at least one non-ionic resin having a mean pore size of 30 nm and a mean particle diameter of 35-120 μm (Amberchrom CG300C) or having a means pore size of 45 nm and mean particle diameter of 560 μm (resin based on aliphatic esters-Amberlite XAD-7HP).
EP 0787500 B1 and EP 0958839 B1 disclose a hydrophobic carrier material having a pore size from 10 to 30 nm and particle sizes from 20 to 350 μm, preferably 10 to 100 μm or 250 to 350 μm, for removing toxic components, in particular cytokines, from a bodily fluid.
EP 1 944 046 B1 discloses a carrier material based on a polystyrene-divinylbenzene copolymer having a pore size of 30 nm and a particle size from 75 to 120 μm.
Tetta et al. (Tetta et al. 1998. Nephrol Dial Transplant 13:1458-1464) describe an adsorber of the Amberchrom CG 300md type having a pore size of 30 nm for removing cytokines from a bodily fluid.
The publication by Cantaluppi et al. (Cantaluppi et al. 2010. Critical Care 14:R4) describes an adsorber of the Amberchrom CG161m type for cytokine adsorption.
It has also been found that anion exchanger resins (for example DEAE or PEI groups bound to cellulose) are very well suited for endotoxin binding. However, the undesirable binding of key factors of the intracorporeal coagulation system, such as protein C and protein S, and the associated coagulation problems are disadvantageous. These coagulation problems can be avoided by the use of a specific adsorber which comprises immobilised antibodies against endotoxins. However, this possibility can only be applied to a limited extent for economical reasons.
In DE 199 13 707 A1, an immune adsorber for use in sepsis therapy for plasmapheresis is described, consisting of a carrier material formed from organic or synthetic polymers and polyclonal or monoclonal antibodies bonded thereto and directed against complement factors, lipopolysaccharides and also against further sepsis mediators, such as TNF-α and interleukins.
DE 10 2004 029 573 A1 discloses an apheresis material or adsorbent and also a method for removing, depleting or inactivating the cytokine MIF (macrophage migration inhibitory factor) from blood, blood plasma or other bodily fluids. The adsorbent comprises a fixed carrier material on the surface of which MIF-binding molecules or functional groups are immobilised.
DE 10 2005 046 258 A1 discloses an immune adsorber for treating insulin resistance and/or the metabolic syndrome, wherein the immune adsorber comprises carrier materials with bonded ligands which are specific for IL-6, IL-4 and C5a.
A therapy form already used for a long time in clinical application is constituted by the parenteral administration of polymyxins. Polymyxins are antibiotic substances which originate initially from the bacteria Bacillus polymyxa and which have already been used for decades in humans and animals in order to treat infections with gram-negative bacteria. Polymyxins interfere with the cell wall structure by increasing the permeability of the cell membrane, thus resulting in cell lysis. Polymyxins bind not only phospholipids, but also endotoxins (LPS) so as to form a polymyxin-endotoxin (LPS) complex with high affinity. The anti-bacterial mechanism of polymyxins is described in detail for example in a publication by Tony Velkov et al. (Tony Velkov et al. 2010. Journal of Medicinal Chemistry: 53(5):1898-1916).
Due to the neurotoxic and nephrotoxic effect of polymyxins, only polymyxin B and polymyxin E (Colistin) have gained a certain therapeutic importance as antibiotic. Until now, these two polymyxins were the only therapeutically admissible representatives of their substance class. Polymyxin B and Colistin are authorised in the USA by the FDA for parenteral infusion. Polymyxin B and Colistin have been used for decades for oral or topical therapy forms. However, for parenteral systemic treatment of conditions and states caused by an infection with gram-negative bacteria, they are only used as antibiotic in a therapeutic context as a last resort due to their neurotoxic and nephrotoxic side effects. Colistin appears to be less nephrotoxic than polymyxin B, however this is offset at least in part by the necessary higher dosing, and therefore nephrotoxic reactions are to be expected to approximately the same extent in everyday clinical practice. However, there is not currently sufficient data available regarding the nephrotoxicity of the two antibiotics. Infectologists from New York (USA) describe kidney failure in 14% of 60 patients treated with polymyxin B. Doctors in Greece describe significant nephrotoxicity in the majority of patients in which renal insufficiency was already present at the start of therapy. By contrast, in patients with normal kidney function, no significant changes were established. A detailed overview concerning the toxicity of polymyxins can be found in a publication by Falagas and Kasiakou (Falagas and Kasiakou. 2006. Critical Care 10:R27). The dosing of polymyxins consequently plays a central role in the avoidance or minimisation of toxic side effects, in particular nephrotoxic side effects.
Due to the occurrence, observed frequently in recent years, of severe progressions of disease caused by infections with multi-resistant pathogenic strains, for example in the case of acute infections with strains of the bacterium Pseudomonas aeruginosa, polymyxins are increasingly being administered parenterally as antibiotic by necessity, in spite of their toxicity. A source of supply for polymyxin B in the form of the sulphate salt of polymyxin B1 and B2 for parenteral administration is currently offered by Bedford Laboratories (“Polymyxin B for Injection 500 000 Units”, manufacturer: Bedford Laboratories). In accordance with manufacturer information, the parenteral administration is carried out intravenously, intramuscularly or, in the case of meningitis, intrathecally, wherein the specified maximum daily dose is generally 2.5 mg/kg body weight per day, divided between two to three infusions. The serum concentration of polymyxin following administration typically lies in a range from 1 to 6 μg/ml. in severe cases this may also be higher in a range from 6 to 50 μg/ml. Colistin is administered predominantly in the form of Colistin methanesulfonate, wherein the serum concentration lies in a range from approximately 1 to 3 μg/ml. Colistin (polymyxin E) is used in a manner similar to polymyxin B, usually in higher dosage.
A resistance to polymyxin B is rather unusual, but may develop if the antibiotic does not reach the cytoplasma membrane due to changes in the outer membrane. Polymyxins are effective against many gram-negative pathogens, such as E. coli, Enterobacter. Klebsiella spp. and also against P. aeruginosa. Proteus types and S. marcescens, which are normally resistant; the sensitivity of B. fragilis is variable. The minimum inhibitory concentrations for E. coli lie in the range from 0.04-3.7 mg/l and for P. aeruginosa between 1.2 and 33.3 mg/l (Garidel and Brandenburg. 2009. Anti-Infective Agents in Medicinal Chemistry, 8:367-385).
Since the dosages for polymyxin B and Colistin used previously in clinical application in the case of parental administration induce nephrotoxic and neurotoxic side effects, new treatment strategies and therapy approaches have been developed in the past in conjunction with the application of endotoxin-binding lipopeptides such as polymyxin.
The extracorporeal blood and/or blood plasma purification methods, already mentioned previously, with use of suitable adsorber materials have become established as frequently applied alternatives to the administration of polymyxins in the form of a drug.
Known adsorber materials comprise porous or fibre-like carrier materials, on the surfaces of which polymyxin B is immobilised. Known neurotoxic and nephrotoxic side effects have been reported previously in conjunction with adsorber materials of this type, which are used to a large extent in the treatment of septic states.
In EP 0110 409 A, polymyxin B-immobilised carriers formed from porous glass (FPG 2000) and also polymyxin B-immobilised polysaccharide carriers based on cellulose (Cellulofine A-3) are disclosed. Microparticles formed from cellulose or derivatised cellulose, to which polymyxin B is covalently bonded, are also known (Weber V., Loth F., Linsberger I., Falkenhagen D.: Int. J. Artif. Organs 25(7), 679). EP 0 129 786 A2 describes an endotoxin detoxification material with a fibre-like carrier, on which polymyxin is covalently immobilised. The fibre-like carrier is equipped with functional groups in order to bind polymyxin covalently to the surface of the carrier. Disadvantages of the specified endotoxin adsorbers include the low endotoxin binding capacity and speed. The efficacy and quality of the treatment in relation to fibre-like carriers with covalently bonded polymyxin B have been described as sub-optimal (Cruz D N et al. 2007. Effectiveness of polymyxin B-immobilized fiber column in sepsis: a systematic review. Crit. Care 11(3):137).
WO 2010/083545 and WO 2011/160149 describe adsorber materials with which polymyxin is immobilised on hydrophobic carrier surfaces via non-covalent interactions (adsorption). WO 2007/142611 A1 and U.S. Pat. No. 5,510,242 describe hydrophobic carrier surfaces with adsorptively bonded polymyxins. The use of polymyxin-coated polyester fabrics for binding LPS antigens of Salmonella typhimurium was described by Blais and Yamazaki (Blais and Yamazaki. 1990. Use of polymyxin-coated polyester cloth in the enzyme immunoassay of Salnmonella lipopolysaccharide antigens. International journal of Food Microbiology 11:195-204).
WO 2011/133287 A1 discloses a blood filtration apparatus, which comprises a microfluidic separation apparatus and with which undesirable substances such as toxins, drugs, pathogens and the like, can be removed from the blood. The apparatus may comprise sensors which monitor the blood in terms of the presence or concentration of the undesirable substances. The monitoring may also include the infusion of therapeutic active ingredients, such as an antibiotic, into the blood of the patient.
An extracorporeal perfusion apparatus of the type mentioned in the introduction has been described for example by Falkenhagen et al. (Falkenhagen et al. 2006. Fluidized Bed Adsorbent System for Extracorporeal Liver Support. Therapeutic Apheresis and Dialysis 10(2):154-159). The filter described therein is obtainable under the trade name “Albuflow®” (Fresenius Medical Care, Germany).
Although the lethality of patients suffering from endotoxemia-induced conditions, in particular sepsis, could be reduced by the clinical application of the above-mentioned polymyxin-based adsorber materials, the lethality of patients with severe sepsis and septic shock is still very high in spite of maximum therapy. For this reason and also due to the ever-increasing problem of the multi-resistance of bacteria to antibiotics and the associated rising incidence of severe progressions of disease, there is also a high demand for improved therapy forms and more efficient extracorporeal perfusion apparatuses, which additionally are quite safe in clinical application.